Provider Demographics
NPI:1639534365
Name:DR STACEY LE, OD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:DR STACEY LE, OD A PROFESSIONAL CORP
Other - Org Name:CIRCLE CITY OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:QUYNHTHY
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-468-3426
Mailing Address - Street 1:807 W GRAND BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-3272
Mailing Address - Country:US
Mailing Address - Phone:951-735-1002
Mailing Address - Fax:
Practice Address - Street 1:807 W GRAND BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3272
Practice Address - Country:US
Practice Address - Phone:951-735-1002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP10232261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU53991Medicare UPIN